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Prescription errors jump to seven at base pharmacy, officials say


The number of prescription errors discovered because of a medication mix-up at the Kitty Hawk satellite pharmacy at Wright-Patterson jumped to seven as of Friday, a base spokesman said.

As of Thursday, base officials had said only one prescription error had been found. Each of the errors were a mixture of a muscle relaxant and acetaminophen, or Tylenol, base spokesman Daryl Mayer said.

“Those seven instances are the only instances we know of where the patients were given the wrong medication,” he said.

The search for prescription mix-ups has been narrowed to 1,273 potentially affected patients who had 2,143 prescription orders refilled between April 23 to April 29 at the Kitty Hawk Pharmacy, Mayer said.

Base officials were still asking those who had an oral medication refilled at that pharmacy between those dates to contact the Wright-Patterson Medical Center. As of Friday afternoon, 277 patients who had a total of more than 500 prescriptions were checked. “If they had pills they need to check it regardless of what pills it was,” Mayer said.

Medical Center personnel will be making telephone calls over the weekend to patients who have not contacted the center, he said.

Pharmacy workers discovered additional medications in an automated system process had mixed medications, but the problem was discovered before the refilled orders were distributed to patients, Mayer said. He did not have an exact number of how many or what kinds of medications that included.

Medical authorities have eliminated patients who had orders refilled for powders, syrups, topical creams, controlled medications and narcotics, officials said. The Kitty Hawk Pharmacy refills about 1,000 prescriptions per day.

A patient who contacted the pharmacy about a prescription error with a muscle relaxant mixed in a bottle with acetaminophen pills sparked warnings from base officials late Tuesday after the discovery. Medical Center personnel contacted other patients who had similar prescriptions and found the additional errors, Mayer said.

A Dayton VA Medical Center pharmacist will temporarily assist the staff at the Kitty Hawk Pharmacy during an ongoing investigation, according to Col. Stephen Higgins, commander of the 88th Medical Group at theMedical Center.

Air Force Medical Operations Agency officials will be on site Monday to investigate what may have gone wrong with an automated, or robotic prescription refilling process, and have not ruled out human error, officials said. Until an answer is known, the Kitty Hawk Pharmacy staff has been refilling prescriptions by hand, officials said.

The automated equipment has regularly scheduled maintenance every six months, most recently last week, a base medical official has said.

The Medical Center has set up a hotline at 937-257-9022 to answer questions or concerns between 6:30 a.m. to 7 p.m. daily. Patients may have their medications checked for accuracy at the Medical Center’s main information desk between 6:30 a.m. to 7 p.m.

“We want to make sure we have the opportunity to check every single one,” Mayer said.

The Ohio State Board of Pharmacy does not have jurisdiction over a federal pharmacy as it does a civilian pharmacy, a board spokesman has said.

However, Wright-Patterson medical pharmacy operations, including the Kitty Hawk Pharmacy, were last inspected two years ago by the Air Force Inspector General and The Joint Commission for hospitals, a national accrediting agency, according to Larine Barr, an Air Force Surgeon General spokeswoman.

The base pharmacies met or exceeded compliance requirements, Barr said in an email. Air Force pharmacies are inspected once every three years.


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